Form Dhhs 1030 - Tuberculosis Epidemiological Record
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1
2N.C. Department of Health and Human Services
1. Last Name
First Name
MI
Division of Public Health
Epidemiology Section • TB Control
2. Patient Number
Tuberculosis Epidemiological Record
3. Date of
Birth
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Patient phone: (H) _______________________________
No phone
Month
Day
Year
(W) ______________________________
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4. Race
1. American Indian/Alaska Native
2. Asian
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(C) _______________________________
3. Black/African American
4. Native Hawaiian/
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Occupation(s): __________________________________
Other Pacific Islander
5. White
6. Unknown
Alternate contact for patient: _______________________
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Ethnicity: Hispanic or Latino Origin?
Yes
No
Unknown
Alternate contact phone: __________________________
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5. Gender
1. Female
2. Male
Primary care MD: ________________________________
None
Primary care MD phone: __________________________
6. County of Residence
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Country of birth
USA
Foreign-born (list) ___________________________________ Date of arrival in US: __________________
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Primary language:
English
Other________________ English proficiency (check all that apply):
Understands
Speaks
Reads
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Can patient read in primary language?
YES
NO
Was an interpreter necessary for this interview?
YES
NO
Reason for presenting to TB clinic:
Allergies:
Wt:
lbs / kg
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Job/administrative screening
Contact investigation
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Refugee/Class B
Outreach screening
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Population risk for TB
Suspected active TB
Medications:
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Medical risk for TB
Confirmed active TB
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Patient referred by a health care provider:
YES
NO
(circle) TST / TSPOT / QFT: Testing site ______________ Date placed________ Date read __________ Result _______ mm / other
(circle) TST / TSPOT / QFT: Testing site ______________ Date placed________ Date read __________ Result _______ mm / other
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Prior treatment for LTBI:
NO
YES (dates) ___________ Prior treatment for active TB:
NO
YES (dates) _______________
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Contact to case?
YES
NO
HIV status:
POS
NEG
Refused
Not Offered
Unknown
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On ART?
YES
NO
Case ID: ____________________________________________
Meds: ___________________________________________________
MEDICAL HISTORY
RISK FACTORS
Average daily alcohol use (circle):
Presumptive treatment / window prophylaxis (TST 0 mm)
None
<1 drink
1-2 drinks
3 or more drinks
Y N
HIV positive and contact to TB
Binge (5 or more drinks in 1 day, not every day)
Y N
Child <5 yrs and contact to TB (window prophylaxis)
(1 drink=12 oz beer=4 oz wine=1 shot liquor)
TST positive at 5 mm
Y N
HIV positive
Tobacco (circle):
Y N
Transplant recipient
Never
Former
Current
Y N
Immunosuppressed (TNF-α inhibitors, ≥15 mg prednisone/day)
Y N
Close contact to TB
Y N
Uses illegal drug besides cocaine/heroin
TST positive at 10 mm
Drug name(s): _____________________________
Y N
Immigrant from high-incidence country
Y N
Pregnant
LMP ___/___/______
Y N
IV drug use (circle drug):
Y N
Using birth control (type) ______________________
Cocaine
Heroin
Other
Y N
Currently breastfeeding
Y N
Crack cocaine use
Y N
Chronic obstructive pulmonary disease
Y N
Silicosis
Y N
Other lung disease (name)
Y N
Diabetes mellitus
_____________________________________________
Y N
Underweight
Y N
Chronic hepatitis B
Height: ___________ in / cm
Y N
Hepatitis C
BMI:
___________
Y N
Other liver disease (name)
Y N
End-stage renal disease (on dialysis)
_____________________________________________
Y N
Cancer of head & neck / lung cancer / lymphoma / leukemia
Y N
Foreign travel to endemic area (place/date)
Y N
Gastrectomy / jejunal bypass
_____________________________________________
Y N
Jail/prison:
Resident
Employee
TB SYMPTOMS
Y N
Incarceration history: _______________________
Y N
Cough
Y N
Homeless shelter:
Resident
Employee
Cough onset: _________________________________
Shelter history: ____________________________
Cough productive: Y
N
Y N
Healthcare worker
Y N
Hemoptysis
Y N
Long-term care facility: Resident
Employee
Y N
Fever
Y N
Child <4 years old
Y N
Night sweats
Y N
Child exposed to high-risk adult
Y N
Chest pain
Y N
Shortness of breath
Nurse: __________________________________________________
Y N
Poor appetite
Y N
Weight loss (amount _______________)
Signature: _______________________________________________
Y N
Swollen glands in neck
Date: ___________________________________________________
Y N
Cervical lymphadenopathy on nurse exam
DHHS 1030 (Revised 03/13)
TB Control (Review 03/16)
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